Apria Healthcare HDHP Customer Service:

Transcription

1 Apria Healthcare HDHP Customer Service: This High Deductible Health Plan is an innovative type of coverage that allows an insured person to use a Health Savings Account to pay for routine medical care, if they choose to do so. The program also includes traditional health coverage, similar to a typical health plan that protects the insured person against large medical expenses. IF YOU OPEN A HSA ACCOUNT: The insured person can spend the money in the HSA account the way the insured person wants on routine medical care, prescription drugs and other qualified medical expenses. There are no copays or deductibles to satisfy first. Unused dollars can be saved from year to year to reduce the amount the insured person may have to pay in the future. If covered expenses exceed the insured person s available HSA dollars, the traditional health coverage is available after a limited out-of-pocket amount is paid by the insured person. Certain Covered Services have maximum visit and/or day limits per year. The number of visits and/or days allowed for these services will begin accumulating on the first visit and/or day, regardless of whether your Deductible has been met. The insured person is responsible for all costs over the plan maximums. Plan maximums and other important information appear in italics. Benefits are subject to all terms, conditions, limitations, and exclusions of the Policy. Explanation of Covered Expense Plan payments are based on covered expense, which is the lesser of the charges billed by the provider or the following: Participating Providers Negotiated rates. Insured persons are not responsible for the difference between the provider s usual charges & the negotiated amount. Non-Participating Providers & Other Health Care Providers (includes those not represented in the PPO provider network) The reasonable charge for institutional services. Pharmacies & Mail Service Program Prescription drugs are carved out to Medco. When using non-participating providers, the insured person is responsible for any difference between the covered expense & actual charges, as well as any deductible & percentage copay. When using the outpatient prescription drug benefits, the insured person is always responsible for drug expenses which are not covered under this plan, as well as any deductible, percentage or dollar copay. Calendar year deductible for all providers (applicable to medical care & prescription drug benefits) Individual insured person Insured family (includes insured employee & one or more members of the employee s family; no coverage may be paid for any member of a family unless this $3,000 deductible is met) Annual Out-of-Pocket Maximums (in-network/out-of-network out-of-pocket maximums are exclusive of each other; includes calendar year deductible & prescription drug covered expense) Participating Providers, Participating Pharmacy & Other Health Care Providers Non-Participating Providers & Non-Participating Pharmacy $1,500/individual insured person $3,000/insured family $3,000/individual insured person; $6,000/insured family/year $6,000/individual insured person; $12,000/insured family/year The following do not apply to out-of-pocket maximums: costs in excess of the covered expense & non-covered expense. After an individual insured person or insured family (includes insured employee & one or more members of the employee s family) reaches the out-of-pocket maximum for all medical and prescription drug covered expense the individual insured person or insured family incurs during that calendar year, the individual insured person or insured family will no longer be required to pay a copay for the remainder of that year. The individual insured person or insured family remains responsible for costs in excess of the covered expense when provided by non-participating providers and other health care providers; non-covered expense. Lifetime Maximum Unlimited Covered Services PPO: Per Insured Non-PPO: Per Insured Hospital Medical Services (preauthorization require for inpatient services; waived for emergency admissions) Semi-private room, meals & special diets, 20%* 50%* & ancillary services Outpatient medical care, surgical services & supplies 20%* 50%* (hospital care other than emergency room care) anthem.com/apria Anthem Blue Cross Life and Health Insurance Company Effective: 1/1/2011 HDHP Benefits

2 Ambulatory Surgical Centers Outpatient surgery, services & supplies 20%* 50%* Hemodialysis Outpatient hemodialysis services & supplies 20%* 50%* 1 Skilled Nursing Facility (subject to utilization review) Semi-private room, services & supplies 20%* 50%* 1 (limited to 60 days/calendar year including residential treatment center) Hospice Care Inpatient services for insured persons 20%* 50%* Outpatient services for insured persons Covered at 100% 3 50%* Bereavement Counseling Inpatient services for insured persons 20%* 50%* Outpatient services for insured persons 20%* 50%* Home Health Care Services & supplies from a home health agency 20%* 50%* 1 (limited to combined maximum of 40 visits/calendar year, one visit by home health aide equals four hours or less; multiple visits can occur in one day; not covered while insured person receives hospice care) Home Infusion Therapy (subject to utilization review) Includes medication, ancillary services & supplies; 20%* 50%* 1 caregiver training & visits by provider to monitor therapy; durable medical equipment; lab services Physician Medical Services Office & home visits 20%* 50%* Hospital & skilled nursing facility visits 20%* 50%* Surgeon & surgical assistant; anesthesiologist or anesthetist 20%* 50%* Allergy Treatment/Injections 20%* 50%* Allergy Serum (dispensed by the physician in the office) 20%* 50%* Well Baby & Well-Child Care for Dependent Children (birth to age eighteen) Routine physical exams No copay 50%* Immunizations No copay 50%* (deductible waived) Physical Exams for Insured Persons Ages Eighteen & Older Routine physical exams, immunizations, diagnostic No copay 50%* X-ray & lab for routine physical exam Immunizations No copay 50%* (deductible waived) Adult Preventive Services (including mammograms, Pap smears, prostate cancer screenings & colorectal cancer screenings; Routine Preventive Care Related Services No copay 50%* Diagnostic Related Services (non-routine) 20%* 50%* Physical Therapy, Speech Therapy, Physical Medicine 20%* 50%* Cardiac Therapy & Occupational Therapy (limited to 90 visits/calendar year for all therapies combined) Pulmonary Rehabilitation & Cognitive Therapy 20%* 50%* Chiropractic Services & Acupuncture Services for the treatment of disease, illness or injury 20%* 2 50%* 2 (limited to 25 visits/calendar year) 2 Acupuncture services can be performed by a certified acupuncturist (C.A.), a doctor of medicine (M.D.), a doctor of osteopathy (D.O.), a podiatrist (D.P.M.), or a dentist (D.D.S.). 3 Covered at 100% after the deductible.

3 Temporomandibular Joint Disorders Splint therapy & surgical treatment Not covered Not covered Diagnostic X-ray & Lab (includes pre-admission testing) Physician s Office Visit 20%* 50%* Emergency Room / Urgent Care Facility(billed as part of the visit) 20%* 2 20%* 2 Independent X-ray and/or Lab Facility 20%* 50%* Advanced Radiology Imaging Physician s Office Visit 20%* 50%* Inpatient Hospital Facility 20%* 50%* Emergency Room / Urgent Care Facility(billed as part of the visit) 20%* 2 20%* 2 Pregnancy & Maternity Care Physician office visits Initial visit to confirm pregnancy 20%* 50%* Normal delivery, cesarean section, complications of pregnancy Delivery Facility 20%* 50%* Inpatient physician services 20%* 50%* Hospital & ancillary services 20%* 50%* Abortion (non-elective covered only) Physician office visits 20%* 50%* Inpatient Facility 20%* 50%* Professional Services 20%* 50%* Organ & Tissue Transplants (subject to utilization review) Inpatient services provided in connection with Covered 100% 3 at CME 50%* non-investigative organ or tissue transplants otherwise 20%* Diabetes Education Programs (requires physician supervision) Teach insured persons & their families about the disease 20%* 50%* process, the daily management of diabetic therapy & self-management training Prosthetic Devices Coverage for breast prostheses; prosthetic devices to 20%* 50%* restore a method of speaking; surgical implants; artificial limbs or eyes; the first pair of contact lenses or eyeglasses when required as a result of eye surgery; & therapeutic shoes & inserts for insured persons with diabetes Durable Medical Equipment Rental or purchase of DME including dialysis equipment & supplies 20%* 50%* 1 Related Outpatient Medical Services & Supplies Ground or air ambulance transportation, services 20%* 2 20%* 1, 2 & disposable supplies Blood transfusions, blood processing & the cost of 20%* 50%* 1 unreplaced blood & blood products Autologous blood (self-donated blood collection, 20%* 50%* 1 testing, processing & storage for planned surgery) 2 Except if not a true emergency, then 50% after the plan deductible. 3 Covered at 100% after the deductible.

4 Emergency Care Emergency room services & supplies 20%* 2 20%* 2 Inpatient and outpatient hospital services & supplies 20%* 20%* Physician services 20%* 2 20%* 2 Urgent Care 20%* 2 20%* 2 Infertility Member cost sharing is based on the type of service performed and the place of service where it is rendered 3 Mental or Nervous Disorders and Substance Abuse Inpatient hospital(subject to utilization review; waived for emergency admissions) 20% 50% Outpatient Facility 20% 50% Inpatient physician visits 20% (deductible waived) 50% (deductible waived) Outpatient physician visits 20% (deductible waived) 50% (deductible waived) 2 Except if not a true emergency, then 50% after the plan deductible. 3 Covered only for diagnosis and treatment of the underlying medical condition In addition to the benefits described above, coverage may include additional benefits, depending upon the insured person s home state. The benefits provided in this summary are subject to federal and California laws. There are some states that require more generous benefits be provided to their residents, even if the master policy was not issued in their state. If the insured person s state has such requirements, we will adjust the benefits to meet the requirements. This Summary of Benefits is a brief review of benefits. Once enrolled, insured persons will receive a Summary Plan Description, which explains the exclusions and limitations, as well as the full range of covered services of the plan, in detail.

5 Apria Healthcare HDHP Plan Exclusions and Limitations Not Medically Necessary. Services or supplies that are not medically necessary, as defined. Bariatric Surgery. Temporomandibular Joint Disorders. Splint therapy & surgical treatment. Experimental or Investigative. Any experimental or investigative procedure or medication. But, if insured person is denied benefits because it is determined that the requested treatment is experimental or investigative, the insured person may request an independent medical review, as described Outside the United States. Services or supplies furnished and billed by a provider outside the United States, unless such services or supplies are furnished in connection with urgent care or an emergency. Crime or Nuclear Energy. Conditions that result from (1) the insured person s commission of or attempt to commit a felony, as long as any injuries are not a result of a medical condition or an act of domestic violence; or (2) any release of nuclear energy, whether or not the result of war, when government funds are available for the treatment of illness or injury arising from the release of nuclear energy. Uninsured. Services received before the insured person s effective date. Services received after the insured person s coverage ends, except as specified as covered Excess Amounts. Any amounts in excess of covered expense or the lifetime maximum. Work-Related. Work-related conditions if benefits are recovered or can be recovered, either by adjudication, settlement or otherwise, under any workers compensation, employer s liability law or occupational disease law, whether or not the insured person claims those benefits. Government Treatment. Any services the insured person actually received that were provided by a local, state or federal government agency, except when payment under this plan is expressly required by federal or state law. We will not cover payment for these services if the insured person is not required to pay for them or they are given to the insured person for free. Services of Relatives. Professional services received from a person living in the insured person s home or who is related to the insured person by blood or marriage, except as specified as covered Voluntary Payment. Services for which the insured person is not legally obligated to pay. Services for which the insured person is not charged. Services for which no charge is made in the absence of insurance coverage, except services received at a non-governmental charitable research hospital. Such a hospital must meet the following guidelines: 1. it must be internationally known as being devoted mainly to medical research; 2. at least 20% of its yearly budget must be spent on research not directly related to patient care; 3. at least one-third of its gross income must come from donations or grants other than gifts or payments for patient care; 4. it must accept patients who are unable to pay; and 5. two-thirds of its patients must have conditions directly related to the hospital s research. Not Specifically Listed. Services not specifically listed in the plan as covered services. Private Contracts. Services or supplies provided pursuant to a private contract between the insured person and a provider, for which reimbursement under Medicare program is prohibited, as specified in Section 1802 (42 U.S.C. 1395a) of Title XVIII of the Social Security Act. Inpatient Diagnostic Tests. Inpatient room and board charges in connection with a hospital stay primarily for diagnostic tests which could have been performed safely on an outpatient basis. Mental or Nervous Disorders. Academic or educational testing, counseling, and remediation. Mental or nervous disorders or substance abuse, including rehabilitative care in relation to these conditions, except as specified as covered Nicotine Use. Smoking cessation programs or treatment of nicotine or tobacco use. Smoking cessation drugs. Orthodontia. Braces and other orthodontic appliances or services. Dental Services or Supplies. Dental plates, bridges, crowns, caps or other dental prostheses, dental implants, dental services, extraction of teeth, or treatment to the teeth or gums, or treatment to or for any disorders for the jaw joint, except as specified as covered Cosmetic dental surgery or other dental services for beautification. Hearing Aids or Tests. Hearing aids and routine hearing tests, except as specified as covered Optometric Services or Supplies. Optometric services, eye exercises including orthoptics. Routine eye exams and routine eye refractions, except routine eye screenings provided as specified as covered Eyeglasses or contact lenses, except as specified as covered in the Certificate. Outpatient Occupational Therapy. Outpatient occupational therapy, except by a home health agency, hospice, or home infusion therapy provider, as specified as covered Outpatient Speech Therapy. Outpatient speech therapy, except as specified as covered Cosmetic Surgery. Cosmetic surgery or other services performed solely for beautification or to alter or reshape normal (including aged) structures or tissues of the body to improve appearance. This exclusion does not apply to reconstructive surgery (that is, surgery performed to correct deformities caused by congenital or developmental abnormalities, illness, or injury for the purpose of improving bodily function or symptomatology or to create a normal appearance), including surgery performed to restore symmetry following mastectomy. Cosmetic surgery does not become reconstructive surgery because of psychological or psychiatric reasons. Commercial Weight Loss Programs. Weight loss programs, whether or not they are pursued under medical or physician supervision. This exclusion includes, but is not limited to, commercial weight loss programs (Weight Watchers, Jenny Craig, LA Weight Loss) and fasting programs. Sex Transformation. Procedures or treatments to change characteristics of the body to those of the opposite sex. Sterilization Reversal. Reversal of sterilization. Infertility Treatment. Any services or supplies furnished in connection with the diagnosis and treatment of infertility, including, but not limited to diagnostic tests, medication, surgery, artificial insemination, in vitro fertilization, sterilization reversal and gamete intrafallopian transfer. Surrogate Mother Services. For any services or supplies provided to a person not covered under the plan in connection with a surrogate pregnancy (including, but not limited to, the bearing of a child by another woman for an infertile couple). Orthopedic Supplies. Orthopedic supplies, orthopedic shoes (other than shoes joined to braces), or non-custom molded and cast shoe inserts, except for therapeutic shoes and inserts for the prevention and treatment of diabetes-related feet complications as specified as covered Air Conditioners. Air purifiers, air conditioners or humidifiers. Custodial Care or Rest Cures. Inpatient room and board charges in connection with a hospital stay primarily for environmental change or physical therapy. Services provided by a rest home, a home for the aged, a nursing home or any similar facility. Services provided by a skilled nursing facility, custodial care or rest cures, except as specified as covered Chronic Pain. Treatment of chronic pain, except as specified as covered Health Club Memberships. Health club memberships, exercise equipment, charges from a physical fitness instructor or personal trainer, or any other charges for activities, equipment or facilities used for developing or maintaining physical fitness, even if ordered by a physician. This exclusion also applies to health spas. Personal Items. Any supplies for comfort, hygiene or beautification. Education or Counseling. Educational services or nutritional counseling, except as specified as covered This exclusion does not apply to counseling for the treatment of anorexia nervosa or bulimia nervosa. Food or Dietary Supplements. Nutritional and/or dietary supplements, except as provided in this plan or as required by law. This exclusion includes, but is not limited to, those nutritional formulas and dietary supplements that can be purchased over the counter, which by law do not requirement either a written prescription or dispensing by a licensed pharmacist. Telephone and Facsimile Machine Consultations. Consultations provided by telephone or facsimile machine. Routine Exams or Tests. Routine physical exams or tests which do not directly treat an actual illness, injury or condition, including those required by employment or government authority, except as specified as covered Acupuncture. Acupuncture treatment, except as specified as covered Acupressure or massage to control pain, treat illness or promote health by applying pressure to one or more specific areas of the body based on dermatomes or acupuncture points. Eye Surgery for Refractive Defects. Any eye surgery solely or primarily for the purpose of correcting refractive defects of the eye such as nearsightedness (myopia) and/or astigmatism. Contact lenses and eyeglasses required as a result of this surgery. Physical Therapy or Physical Medicine. Services of a physician for physical therapy or physical medicine, except when provided during a covered inpatient confinement or as specified as covered Outpatient Prescription Drugs and Medications. Outpatient prescription drugs, medications and insulin, except as specified as covered Non-prescription, over-the-counter patent or proprietary drugs or medicines. Cosmetics, health or beauty aids. Contraceptive Devices. Contraceptive devices prescribed for birth control except as specified as covered Diabetic Supplies. Prescription and non-prescription diabetic supplies except as specified as covered Private Duty Nursing. Inpatient or outpatient services of a private duty nurse. Lifestyle Programs. Programs to alter one s lifestyle which may include but are not limited to diet, exercise, imagery or nutrition. This exclusion will not apply to cardiac rehabilitation programs approved by us. Wigs. Pre-Existing Conditions No payment will be made for services or supplies for the treatment of a pre-existing condition during a period of six months following either: (a) the insured person s effective date or (b) the first day of any waiting period required by the group, whichever is earlier. However, this limitation does not apply to a child born to or newly adopted by an enrolled employee or spouse/domestic partner, or to conditions of pregnancy. Also if an insured person was covered under creditable coverage, as outlined in the insured person s Certificate, the time spent under the creditable coverage will be used to satisfy, or partially satisfy, the six-month period. Third Party Liability Anthem Blue Cross Life and Health Insurance Company is entitled to reimbursement of benefits paid if the insured person recovers damages from a legally liable third party. Coordination Of Benefits The benefits of this plan may be reduced if the insured person has any other group health or dental coverage so that the services received from all group coverages do not exceed 100% of the covered expense. Anthem Blue Cross Life and Health Insurance Company is an independent licensee of the Blue Cross Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association.